If hot flashes, vaginal dryness and bone loss are taking over your life, read on for the latest non-estrogen menopause treatments that may bring you relief...

As women age and enter menopause, we start producing less of the hormones that regulate certain areas of our body, resulting in those pesky signs of menopause: hot flashes, vaginal symptoms, bone loss and more.

To replace vanishing hormones, doctors often prescribe estrogen, or a combination of estrogen and progesterone, for women in menopause.

“For many women, hormone therapy is safe and appropriate,” says Lauren Streicher, M.D., a gynecologist and associate clinical professor at Northwestern University Feinberg School of Medicine.

However, many women can’t use estrogen therapy because of a history of breast or uterine cancer, among other reasons. Or they’re put off by the risks associated with them, which may include:

Stroke

Blood clots in the legs or lungs

Breast cancer, for estrogen-progestin therapy

Endometrial cancer, for estrogen-only therapy

Gallbladder disease

Urinary incontinence

If you can’t take estrogen, other treatments can help relieve menopause-related problems.

“Never before have we had so many options for treating symptoms of menopause,” says Cynthia Evans, M.D., an obstetrician/gynecologist and associate professor at Ohio State University Wexner Medical Center in Columbus.

Women have been clamoring for more choices. In a 2013 survey by the North American Menopause Society (NAMS), 90% of women who responded – most of whom had moderate to severe hot flashes – said nonhormonal therapies are needed. When NAMS conducted a similar survey among its professional members, 94% agreed that they’d like to see a wider variety of nonhormonal treatments.

Hormone use among postmenopausal women in the U.S. declined from 22.4% in 1999-2000 to 4.7% in 2009-2010, according to the National Health and Nutrition Examination Survey, a series of studies sponsored by the Centers for Disease Control and Prevention.

Read on for some cutting-edge menopause treatments for common symptoms.

Hot Flashes
About three-fourths of women experience hot flashes during menopause, according to the American College of Obstetricians and Gynecologists (ACOG).

Although some women have hot flashes only occasionally, “others may have 12-20 hot flashes daily that interfere with their lives during the day and wake them up at night,” Dr. Streicher says. “In most women with moderate to severe hot flashes, they last for 3-5 years – and in 10%, they last for life.”

In 2013, a low-dose version of the antidepressant paroxetine became the first nonhormonal drug to be approved by the Food and Drug Administration (FDA) for treating menopausal hot flashes.

Paroxetine is an SSRI (selective serotonin reuptake inhibitor), a common type of antidepressant that increases the brain’s supply of serotonin. The hormone may relieve hot flashes by affecting the temperature-regulating center in the brain, Dr. Evans explains.

“In clinical trials, the reduction in number and severity of hot flashes with estrogen is typically 70%-80%,” she says. “With [paroxetine], it’s more in the range of 60%.”

Watch out: Headache, fatigue, nausea and vomiting are paroxetine’s most common side effects. However, the daily dose of paroxetine in a name-brand hot flash product is 7.5 mg, lower than the dose used to treat depression (up to 40 mg). As a result, the risk of side effects, such as weight gain and a loss of sex drive, is low. That’s a big advantage for postmenopausal women, who may already be struggling with their weight and libido, Dr. Streicher says.

Other antidepressants
If you have both hot flashes and depression, you might be able to treat both with other SSRIs and their antidepressant cousins, serotonin-norepinephrine reuptake inhibitors (SNRIs), according to ACOG.

For example, desvenlafaxine, a SNRI, reduced hot flashes in a 2013 study led by the University of Virginia Health Sciences Center in Charlottesville, published in the journal Menopause. The postmenopausal participants still were doing well after a year on the drug.

Other options include:

Gabapentin
This medication, used for treating seizures and nerve pain in people with epilepsy, bipolar disorder and fibromyalgia, may also cool off hot flashes. In addition, it decreased disruptions in sleep, according to another 2013 University of Virginia study.

It’s an “effective alternative to hormone therapy,” according to ACOG, but the FDA hasn’t approved it for that purpose.

Gabapentin GR, an extended-release form of the drug, was only modestly effective against hot flashes, the University of Virginia researchers found.

Doctors aren’t certain how gabapentin reduces hot flashes, says Jill Rabin, M.D., co-chief of Women’s Health Programs at North Shore-LIJ Health System in New York. It’s thought to affect the flow of calcium in and out of cells, which plays a role in regulating body temperature, she says.

Watch out: Dizziness, headache and drowsiness were the most common side effects.

“Side effects can usually be reduced by gradual adjustment of the dose,” Dr. Rabin says.

For Vaginal Symptoms
Menopause leads to thinning and shrinking of vaginal tissue, so it may not stretch and produce moisture the way it once did. That can make sex uncomfortable and may leave women more vulnerable to yeast infection or bacterial imbalance. The accompanying itching and burning make the problem worse, Dr. Evans says.

Over-the-counter vaginal lubricants are the first line of defense, she says. But if they don’t ease your symptoms enough, you may need prescription-strength help.

Estrogen – released through a ring, cream or tablet inserted into the vagina – is the gold standard for treatment. Nevertheless, the FDA approved in 2013 ospemifene, an oral drug for treating painful intercourse because of menopause.

Ospemifene
This pill is a selective estrogen receptor modulator (SERM), a class of medication that includes the breast cancer drug tamoxifen.

“A SERM goes to estrogen receptors in the body and turns some of them on and off,” Dr. Evans says.

Watch out: In the vagina, ospemifene turns on receptors, acting as estrogen would, making vaginal tissue thicker and less tender. But it also stimulates the endometrium (lining of the uterus) like estrogen, which can raise the risk for endometrial cancer.

If you have unusual vaginal bleeding while taking the drug, talk to your doctor, Dr. Evans says. Like estrogen, ospemifene may also increase your risk for stroke and blood clots.

Bone Loss
During the menopausal transition, the dramatic drop in natural estrogen can trigger rapid bone loss. After a few years, the rate slows but continues in postmenopause. Ultimately, this may lead to osteoporosis, a disease in which bones weaken and break easily.

Zoledronic acid “has a clear advantage when it comes to convenience,” Dr. Camacho says. “But the three oral forms are still popular too.”

Only alendronate is available in generic form, “so it’s going to be the cheapest,” she says.

Watch out: Side effects of IV bisphosphonates include flulike symptoms, such as fever, headache and achy muscles or joints. Side effects of oral bisphosphonates include nausea, heartburn and stomach pain.

In rare cases, bisphosphonate use has been linked to deterioration of the jawbone or unusual fractures in the thighbone. This is more common after prolonged use, which is why patients often take a temporary break from treatment after five to 10 years, Dr. Camacho says.

Dr. Camacho and her colleagues reported on the first head-to-head comparison of denosumab and zoledronic acid in a study presented at the 2013 meeting of the American Society for Bone and Mineral Research.

Denosumab, leading to a greater increase in bone density, came out the winner. However, patients in the study weren’t randomly assigned to the two treatments, so more research is still needed.

“Based on what we found, it’s a lot easier for me to recommend one over the other now,” Dr. Camacho says.

Watch out: Side effects include low calcium levels, muscle pain, back pain, infections and skin rashes. In rare cases, use of this drug may lead to deterioration of the jawbone, she says.

Raloxifene
This SERM acts like estrogen in the bones, but blocks the effects of estrogen in the breast and uterus.

Because Raloxifene has anti-estrogen effects in the breast, it might seem like a good choice for women with estrogen-sensitive breast cancer. However, Dr. Camacho notes that many of these women take tamoxifen, another SERM used in breast cancer treatment.

“Doctors are wary of adding a second anti-estrogen drug on top of that,” she says.

The pill is taken orally once a day.

“This drug isn’t as powerful as the bisphosphonates and denosumab, so I would generally limit its use to patients who aren’t as high risk for fractures,” Dr. Camacho says.

Watch out: Side effects can include – unfortunately – hot flashes and, for some women, an increased risk of blood clots.

Teriparatide
Teriparatide, a form of human parathyroid hormone, promotes the formation of new bone. It’s taken as a daily injection for as long as two years.

“This drug is reserved for people with severe osteoporosis,” Dr. Camacho says.

It might be a good option for someone who has suffered multiple fractures or who isn’t doing well on bisphosphonates or denosumab, she adds.

Watch out: Side effects include leg cramps and dizziness.

Calcitonin
This hormone slows bone loss and reduces the risk of spinal fractures. It may be taken as a daily nasal spray or injection to treat osteoporosis in women who are at least five years past menopause.

Watch out: “It’s weak,” Dr. Camacho says. “It has been shown to reduce fractures by about 20%, and the increases in bone density are minimal.”

As a result, she says, it’s typically used only as a last resort.

Side effects include nausea, flushing, swelling or joint pain; the nasal spray can cause runny nose, nosebleed or sinus pain.

Are You in Perimenopause?Do you suspect you might be in perimenopause, the period of time leading up to menopause? It can occur as early as your late 30s. But remember, you can still be years away from menopause even if you’re experiencing the symptoms. Take our perimenopause quiz to assess whether menopausal changes are upon you.

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